الفهرس 
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Abstract
Cognitive functions are informative in indicating how well the patient functions in daily living,
and thus facilitate a more accurate assessment of occupational and social functioning, which in turn
aid treatment planning and design of rehabilitation programs. People with schizophrenia who
participate in cognitive rehabilitation are more likely to benefit from the programs if they are
intrinsically motivated to work on the tasks to improve their cognition. So, it is vital to psychiatric
nurses to assess and understand impairments in cognitive functions in their patients and how these
disturbances affect the functional outcomes.
The present study has two main goals, namely examining the relationship between
functional outcomes, intrinsic motivation, and cognitive functions of patients with schizophrenia and
determining the effect of Cognitive and Motivational Enhancement Interventions on cognitive
functions and intrinsic motivation of patients with schizophrenia.
This study hypothesized that there is a relationship between functional outcomes, intrinsic
motivation, and cognitive functions in patients with schizophrenia. Intrinsic motivation moderates the
relationship between cognitive functions, and functional outcomes. Intrinsic motivation moderates
the relationship between cognitive functions, and functional outcomes. In addition, Cognitive and
Motivational Enhancement Interventions have a positive effect on cognitive functions and intrinsic
motivation of those patients”.
The present study followed a correlational/experimental design. It was conducted in 6
psychiatric inpatient units of EL-Maamoura Hospital for Psychiatric Medicine in Alexandria.
The subjects of the study included one–hundred male in-patients with a DSM-IV diagnosis of
schizophrenia to collect baseline data and respond to the first aim of the study. 60 of these 100 inpatients
were assigned randomly to the study and control groups, 30 patients for each group to respond to second aim of the study.
The following tools were used:
Motivational Trait Questionnaire (MTQ) Short Form, developed by Heggestad and Kanfer
(2000) (150), which is a 48-item self-report scale that measures three broad motivational traits.
Cognitive Functions Battery, composed of several cognitive functions tests which measure
memory, attention and executive functions among patients with schizophrenia.
a. Trail Making Test (TMT) standardized by Reitan (1995) (151) is a good predictor of general
mental ability especially attention functions and motor speed. The test consists of two parts,
A and B.
b. Rey Auditory-Verbal Learning Test (RAVLT) developed by Rey (1958) (152). This test
measures short-term, long-term, and recognition memory.
c. Clock-Drawing Test developed by Royall (1998) (155). The CDT is reliable measure for executive functions. It has been divided into two parts.
The Multnomah Community Ability Scale (MCAS) are firstly created in 1983 by community
mental health case managers (156). It measures the degree of functional ability of patient in the last
month in the community.
The socio-demographic and clinical data questionnaire developed by the researcher.
MTQ, cognitive battery and MCAS were translated into Arabic language. All tools were then tested
for content validity and accuracy of the translation by a jury of nine experts and modification was done
accordingly. The internal consistency for tool I and test-retest reliability for tool II & III were
performed by the researcher on ten patients with schizophrenia taking into consideration the inclusion
and exclusion criteria over period of one month.
The internal consistency of MTQ scales showed high correlation (i.e., Desire to Learn, α =0 .81;
mastery, α =0 .82; Other Referenced Goals, α = 0.83; Competitiveness, α = .89; Worry, α = 0.84;
Emotionality, α = 0.80). In regard, to cognitive battery, TMT showed high positive correlation (rho =
0.85). The CDT showed high correlation (rho = 0.73 for CLOX 1 and rho = 0.90 for CLOX 2) and the
RAVLT demonstrated significant moderate to high positive correlation (rho = 0.69). Additionally,
intra-class correlation coefficients of MCAS were (0.96) for the total and (0.87-0.99) for the subscale
scores.
A pilot study was conducted on ten patients with schizophrenia, and modification was done
accordingly. The actual study was conducted in three stages:
Assessment phase:
A random selection of the hospital wards was done using simple randomization to identify
priority sequence of the six wards. In each ward, the selected patients were assessed for their intrinsic
motivation, cognitive functions, functional outcomes and socio-demographic and clinical
characteristics, using tool I, II, III, and IV respectively. After that, 60 patients from them were
randomly assigned to joint either the study or the control group as 30 patients for each group. At the
end matching was done between the study and control groups.
Phase two :
This phase was directed toward implementation of the cognitive and motivational enhancement
interventions. It was carried out for those included in the study group, while patients of the control
group were left to undergo the usual hospital routine care. The interventions consisted of 30 sessions
for cognitive enhancement; each session lasted about 20-30 minutes, 6 times a week for 5 weeks.
Meanwhile, the motivational enhancement consisted of 4 sessions; each session lasted about 60-90 minutes, one time a week for 4 weeks.
Phase three:
This phase is concerned with evaluation of the effectiveness of the cognitive and motivational
enhancement interventions through reapplication of tool I and II for the study and control groups.
Data was coded, computerized, analyzed, and presented using Statistical Package for Social
Science (SPSS) software package version 20.0.
The following are the main results of the present study
The age of the studied subjects ranged from 20–56 years with a mean age of 34.91 ± 8.68 years.
73% of them were single and 11% were married. Those with preparatory or secondary school
education amounted to 73% and 60% were unemployed. The majority of the studied patients
(72%) were living in urban areas and 62% of them were living with their family. 68% of them
suffered from schizophrenia for more than 5 years. Those admitted for up to 4 times or more were
49% and 46% were hospitalized for 14 to 21days. As regard to treatment 49% of the studied
patients received typical antipsychotic drugs and the majority of them 89% received
anticholinergic drugs, while only 25% received mood stabilizer drugs.
The Memory function showed that 42% of the studied subjects had high memory impairment
according to the sum of short and long-term memory scores. The short-term memory of the
studied subjects showed a significant gradual increase in memory capacity after several
presentations of the same items.
The attention function showed that the majority studied subjects had poor attention function
(77%); with a mean score of 135.92 ± 70.51 sec.
The majority of the studied subjects (89%) had poor executive functions performance at CLOX1
and 78% of them had poor executive functions performance at CLOX2.
Concerning the intrinsic motivation, the mean score of “Desire to learn” and “mastery goals”
were 32.34±7.19 and 28.91±8.10 respectively. While, the “Other-Referenced Goals” and
“Competitiveness” showed the mean scores 22.79±7.83 and 16.56±7.17 respectively. The
“Worry” and “Emotionality” had mean scores of 32.76±11.72 and 6.51 ± 3.39 respectively.
Regarding, the functional outcomes of the studied subjects. The “physical health” indicator
showed mean score of 4.75 ± 0.50. While, the second section, “Ability to Manage Money”,
“Independence in Daily Life” and “Acceptance of Illness” showed a mean scores 2.19 ±1.18,
2.90 ± 1.29 and 2.03 ± 1.27 respectively. The “social net-work” indicator illustrated the mean
score of 1.90 ± 0.77. Finally, the fourth section, concerning its indicator “Medication
Summary
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Compliance”, the majority of the studied patients did not take medication independently; and
non-compliant with treatment, with mean score 2.93 ± 1.28.
A significant positive correlation between total intrinsic motivation and both memory and
executive functions (r =0.230 and r =0.191respectively) was found. A strong significant negative
correlation between total intrinsic motivation and attention function (r=- 0.210) was found.
Memory function had a significant positive correlation with two sections Interference with
Functioning and Adjustment to Living (r=0.210 and 0.216 respectively). Executive function
showed a strong positive correlation with Adjustment to Living (CLOX1r= 0.309 and CLOX2=
0.239 respectively). In addition, attention function had a strong significant negative correlation
with Interference with Functioning and Adjustment to Living sections (r =-0.194 and -0.278
respectively).
A significant correlation was found between total intrinsic motivation and two functional
outcomes namely “Adjustment to Living” and “Social Competence” (r= 0.217 and 0.202 respectively).
Regarding the functional outcomes, the stepwise technique revealed that the desire to learn
subtrait was the only predictor for functional outcomes
Results of Cognitive and Motivation Enhancement Interventions:
The cognitive functions of the study group showed a significant improvement after implementing
the cognitive enhancement interventions:
The mean scores of the study group showed significant improvements in all attempts of
memory function test after participation in the cognitive enhancement intervention sessions
than the control group (P= 0.001 for all attempts).
Attention function improved significantly post-implementing the intervention among the
study than control group (t-test=10.353, P= 0.001).
The executive function of the study group showed high performance when measured by CDT,
as improved from 3.3% on CLOX1 to 13.3% and 6.7% on CLOX2 to 33.3% after
implementing the interventions.
Regarding, the intrinsic motivation, t-test results showed the study group had significantly more
improvements in the mean scores of all subtraits after participation in the interventions sessions
than the control group (t-test=1.768, 2.099, 2.962, 3.606, 3.240 and 2.799 respectively).
It can thus be concluded that neurocognitive impairments and intrinsic motivation were related to
functional outcome among patients with schizophrenia. Moreover, functional outcomes can be
predicted only through desire to learn subtraits of intrinsic motivation. Furthermore, the combination
of cognitive and motivational enhancement interventions can bring a significant improvement in
intrinsic motivation and cognitive functions among hospitalized patients with schizophrenia.
The following are the main recommendations yielded by the study:
1. Assessment of the intrinsic motivation, neurocognitive functions and functional outcomes
(activities of daily living, social functioning and employment) needs to be incorporated into
routine clinical assessment of patients with schizophrenia, in order to consider appropriate
psychiatric nursing care and interventions.
2. Psychiatric nurses need to be trained to take an active role in delivering the cognitive and
motivational enhancement interventions effectively in the in-patient settings and extend to outpatient
and community settings.
3. Examine the effectiveness of both the Cognitive and Motivational Enhancement Interventions on
functional outcomes of the patients with schizophrenia in community settings such as outpatient
clinics and community mental health service.
4. Neurocognitive impairments, intrinsic motivation, functional outcomes of patients with
schizophrenia, in addition to cognitive and motivational enhancement interventions should be
included in nursing curriculum of Psychiatric Nursing and Mental Health since these areas appear
to be promising in the care and management of patients with schizophrenia.
The previous results are applicable in improving social skills training for patients with
schizophrenia. For successful skill acquisition, patients need to encode and recall material
presented. So, the instructor must repeat the instructions several times to the patients, giving only
one piece of information at a time, and this information must be clear and direct.